Simpra Advantage (PPO SNP) 2018 Comprehensive …

1 Simpra Advantage (PPO SNP) 2018 Comprehensive formulary List of covered Drugs PLEASE READ: THIS DOCUMENT CONTAINS INFORMATION ABOUT THE DRUGS WE COVER IN THIS PLAN HPMS Approved formulary File Submission ID, 00018347 Version 17 This formulary was updated on 11/01/ 2018 . For more recent information or other questions, please contact Simpra Advantage Member Services at 1-844-637-4770 or, for TTY users, 711, Hours of operations: 8 to 8 , seven days a week (except Thanksgiving and Christmas) from October 1 through February 14, andMonday to Friday (except holidays) from February 15 through September 30, or visit Simpra Advantage is an PPO plan with a Medicare contract. Enrollment in Simpra Advantage depends on contract renewal. Simpra complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Simpra cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo.

2 Simpra ATENCI N: si habla espa ol, tiene a su disposici n servicios gratuitos de asistencia ling stica. Llame al 1-844-637-4770 TTY: 711. 1-844-637-4770 TTY 711 H4091_2018_drug01 Accepted 1 Note to existing members: This formulary has changed since last year. Please review this document to make sure that it still contains the drugs you take. When this drug list ( formulary ) refers to we, us , or our, it means Simpra Advantage . When it refers to plan or our plan, it means Simpra Advantage . This document includes a list of the drugs ( formulary ) for our plan which is current as of 11/01/ 2018 . For an updated formulary , please contact us. Our contact information, along with the date we last updated the formulary , appears on the front and back cover pages. You must generally use network pharmacies to use your prescription drug benefit.

3 Benefits, formulary , pharmacy network, and/or copayments/coinsurance may change on January 1, 2018 , and from time to time during the year. 2 What is the Simpra Advantage formulary ? A formulary is a list of covered drugs selected by Simpra Advantage in consultation with a team of health care providers, which represents the prescription therapies believed to be a necessary part of a quality treatment program. Simpra Advantage will generally cover the drugs listed in our formulary as long as the drug is medically necessary, the prescription is filled at an Simpra Advantage network pharmacy, and other plan rules are followed. For more information on how to fill your prescriptions, please review your Evidence of Coverage. Can the formulary (drug list) change? Generally, if you are taking a drug on our 2018 formulary that was covered at the beginning of the year, we will not discontinue or reduce coverage of the drug during the 2018 coverage year except when a new, less expensive generic drug becomes available or when new adverse information about the safety or effectiveness of a drug is released.

4 Other types of formulary changes, such as removing a drug from our formulary , will not affect members who are currently taking the drug. It will remain available at the same cost-sharing for those members taking it for the remainder of the coverage year. We feel it is important that you have continued access for the remainder of the coverage year to the formulary drugs that were available when you chose our plan, except for cases in which you can save additional money or we can ensure your safety. If we remove drugs from our formulary , or add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, we must notify affected members of the change at least 60 days before the change becomes effective, or at the time the member requests a refill of the drug, at which time the member will receive a 60-day supply of the drug . If the Food and Drug Administration deems a drug on our formulary to be unsafe or the drug s manufacturer removes the drug from the market, we will immediately remove the drug from our formulary and provide notice to members who take the drug.

5 The enclosed formulary is current as of 11/01/ 2018 . To get updated information about the drugs covered by Simpra Advantage , please contact us. Our contact information appears on the front and back cover pages. In the event that Simpra Advantage has CMS-approved non-maintenance changes to the formulary throughout the plan year ( remove drugs from our formulary , add prior authorization, quantity limits and/or step therapy restrictions on a drug, or move a drug to a higher cost-sharing tier, Simpra Advantage will update our formulary and post in on our website. How do I use the formulary ? There are two ways to find your drug within the formulary : Medical Condition The formulary begins on page 7. The drugs in this formulary are grouped into categories depending on the type of medical conditions that they are used to treat. For example, drugs used to treat a heart condition are listed under the category, Cardiovascular Agents-Misc.)

6 If you know what your drug is used for, look for the category name in the list that begins on page 7. Then look under the category name for your drug. Alphabetical Listing If you are not sure what category to look under, you should look for your drug in the Index that begins on page 109. The Index provides an alphabetical list of all of the drugs included in this document. Both brand name drugs and generic drugs are listed in the Index. Look in the Index and find your drug. Next to your drug, you will see the page number where you can find coverage information. Turn to the page listed in the Index and find the name of your drug in the first column of the list. 3 What are generic drugs? Simpra Advantage covers both brand name drugs and generic drugs. A generic drug is approved by the FDA as having the same active ingredient as the brand name drug. Generally, generic drugs cost less than brand name drugs.

7 Are there any restrictions on my coverage? Some covered drugs may have additional requirements or limits on coverage. These requirements and limits may include: Prior Authorization (PA): Simpra Advantage requires you [or your physician] to get priorauthorization for certain drugs. This means that you will need to get approval from SimpraAdvantage before you fill your prescriptions. If you don t get approval, Simpra Advantage may notcover the drug. Prior Authorization Restriction for Part B vs Part D Determination (PA BvD): This drug may beeligible for payment under Medicare Part B or Part D. You (or your physician) are required to get priorauthorization from Simpra Advantage to determine that this drug is covered under Medicare Part Dbefore you fill your prescription for this drug. Without prior approval, Simpra Advantage may notcover this drug. Prior Authorization Restriction for New Starts Only (PA NSO): If you are a new member, you (oryour physician) are required to get prior authorization from Simpra Advantage before you fillyourprescription for this drug.

8 Without prior approval, Simpra Advantage may not cover this drug. Quantity Limits (QL): For certain drugs, Simpra Advantage limits the amount of the drug that SimpraAdvantage will cover. For example, Simpra Advantage provides 9 tabs per prescription for sumatriptantab. This may be in addition to a standard one month or three-month supply. Step Therapy (ST): In some cases, Simpra Advantage requires you to first try certain drugs to treatyour medical condition before we will cover another drug for that condition. For example, if Drug Aand Drug B both treat your medical condition, Simpra Advantage may not cover Drug B unless you tryDrug A first. If Drug A does not work for you, Simpra Advantage will then cover Drug B. Non-Mail-Order Drug (NM): You may be able to receive greater than a 1-month supply of most of thedrugs on your formulary via mail order at a reduced cost share. Drugs not available via your mail-orderbenefit are noted with NM in the notes column of your formulary .

9 Limited Distribution (LD): The symbol (LD) next to a drug name indicates that the drug has beennoted as being restricted to certain pharmacies by the Food and Drug Administration. These drugs canonly be obtained at specialty designated pharmacies able to appropriately handle can find out if your drug has any additional requirements or limits by looking in the formulary that begins on page 7. You can also get more information about the restrictions applied to specific covered drugs by visiting our Web site. We have posted on line documents that explain our prior authorization restriction and step therapy restrictions. You may also ask us to send you a copy. Our contact information, along with the date we last updated the formulary , appears on the front and back cover pages. 4 You can ask Simpra Advantage to make an exception to these restrictions or limits or for a list of other, similar drugs that may treat your health condition.

10 See the section, How do I request an exception to the Simpra Advantage s formulary ? on this page for information about how to request an exception. What if my drug is not on the formulary ? If your drug is not included in this formulary (list of covered drugs), you should first contact Member Services and ask if your drug is covered . If you learn that Simpra Advantage does not cover your drug, you have two options: You can ask Member Services for a list of similar drugs that are covered by Simpra you receive the list, show it to your doctor and ask him or her to prescribe a similar drug that iscovered by Simpra Advantage . You can ask Simpra Advantage to make an exception and cover your drug. See below forinformation about how to request an do I request an exception to the Simpra Advantage formulary ? You can ask Simpra Advantage to make an exception to our coverage rules.